Provider Demographics
NPI:1679012918
Name:TUNNEL ROAD OPTOMETRY GROUP OD PA
Entity Type:Organization
Organization Name:TUNNEL ROAD OPTOMETRY GROUP OD PA
Other - Org Name:DAVIS EYE KERNERSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-909-0160
Mailing Address - Street 1:1011 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8186
Mailing Address - Country:US
Mailing Address - Phone:336-993-0566
Mailing Address - Fax:336-993-0567
Practice Address - Street 1:3316 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3011
Practice Address - Country:US
Practice Address - Phone:336-765-5350
Practice Address - Fax:336-765-0769
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUNNEL ROAD OPTOMETRY GROUP OD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty